Question 1

The nurse is caring for a client who is in active labor and has just had an amniotomy. The nurse notes that the fetal heart rate has decreased from 140 bpm immediately prior to the amniotomy to 95 bpm. Upon vaginal examination, the nurse feels a portion of the umbilical cord in the vagina. Which is the nurse's next action in caring for this client?
A)Carefully push the umbilical cord back into the vagina with a sterile gauze.
B)Immediately place the client in reverse Trendelenburg and prepare to move the client to the operating room for a caesarean section.
C)Assist the client to the knee-chest position and notify the healthcare provider.
D)Place oxygen on the client at 2 L/min per nasal cannula and turn the client to the left side.

Accepted Answer

If the umbilical cord is palpated in the vagina, the nurse should assist the client to the knee-chest position as quickly as possible and hold pressure on the presenting part to keep it off the cord and notify the healthcare provider.

Question 2

The nurse is assisting the health care provider with the first prenatal exam of a client. Prior to the vaginal speculum examination, which information should the nurse give the client to improve the client's comfort during the examination?
A)"Right when the speculum is being inserted in your vagina, you should hold your breath."
B)"As the speculum is being inserted, clench your fists as tightly as possible."
C)"It will help if you begin to do isometric exercises with your hands so you won't think about the speculum being inserted in your vagina."
D)"You need to bear down as the speculum is being inserted because it will help you relax."

Accepted Answer

Asking the client to bear down at the time of speculum insertion helps to open the vaginal orifice and relaxes the perineal muscle.

Question 3

The nurse is caring for a client who is prescribed to have labor induced with oxytocin. Which assessments must be completed by the nurse before initiating the oxytocin infusion? Select all that apply.
A)Record the fetal heart rate for 15 minutes.
B)Obtain the client's pain level.
C)Explain to the client that she should expect to be nauseated.
D)Determine the client's hydration status.
E)Apply the tocodynamometer and observe for any contractions.

Accepted Answer

Prior to beginning the infusion, a baseline of fetal activity should be established.
It is important to establish the client's hydration status so that uterine hyperstimulation can be avoided.
A baseline of uterine activity should be established before medicating the client.

Question 4

The nurse has completed applying the ultrasound transducer to the client's abdomen and has confirmed that the rate is not the same as the client's. Which other assessment will assist the nurse in confirming that the sound that is heard is the true fetal heart rate (FHR)?
A)The rate is slightly different at each assessment time.
B)The sound of the FHR is louder than the sound of the contraction.
C)The FHR will be approximately twice the rate of the client.
D)The FHR will have a whip-like sound.

Accepted Answer

The FHR will have a whip-like sound, which will help confirm that the sound heard is the fetal heart rate.

Question 5

The nurse is discussing anticipated weight gain with a client who has a BMI of 32. Which statement by the client indicates understanding of the topic?
A)"I know that because I am overweight that my baby already has access to sufficient nutrients and I should attempt to keep my weight stable through the pregnancy."
B)"No matter what you weigh when you are pregnant, you should attempt to gain 25 to 30 lb so that my baby will be born healthy."
C)"I will need to watch what I eat and make sure that I am eating a nutritious diet and I will try and limit by weight gain to less than 20 lb."
D)"I will limit what I eat while I am pregnant so I can begin to lose weight and to ensure that my baby is not born fat."

Accepted Answer

An obese woman should watch her diet to ensure that the calories she consumes are the most nutritious and attempt to limit weight gain to 15 to 20 lb.

Question 6

The nurse is caring for a woman who has been diagnosed with preeclampsia and has been placed on intravenous magnesium sulfate to prevent seizures. After checking the patellar deep tendon reflex, the nurse documents the response as 2+. Which is the nurse's next action after this assessment?
A)Immediately discontinue the magnesium sulfate because the patellar response indicates hyporeflexia.
B)Check the deep tendon reflex in the biceps to see if it agrees with the patella.
C)Turn the client on her side to prevent aspiration during the anticipated seizure.
D)Ensure that the IV site is patent and that the magnesium sulfate is infusing adequately.

Accepted Answer

It is common for the nurse to check two different reflexes, so the nurse would assess another reflex after assessing the patella.

Question 7

The nurse is performing the first Leopold maneuver on a client of 34 weeks gestation and notes the presence of fetal bottom and legs. The nurse knows that this maneuver would indicate which for this client?
A)The fetus' head is in the pelvis but positioned in a posterior fashion.
B)The fetus is in a breech position and a caesarean section may be required at birth.
C)The fetus' size does not match its gestational age.
D)The fetus is in position for immediate delivery and the healthcare provider should be notified immediately.

Accepted Answer

The presence of bottom and feet indicates that the fetus is in a breech position and a caesarean section may be necessary at birth.

Question 8

The nurse receives a call from a primapara who is at 37 weeks gestation. The client states, "I just wanted to let you know that we are on our way to the hospital. All of a sudden, my belly dropped so I know that I will be delivering the baby very soon." Which is the nurse's best response to this client?
A)"Just stay home because there is no way to tell when your labor will start."
B)"If you would like to come in and be checked that will be fine, but this drop only indicates your baby is getting ready for labor, not that it will start soon."
C)"I think you need to come in because once the head drops, labor can begin at any minute."
D)"I can't stop you from coming in, but I don't recommend it. You are just going to have a long wait for nothing."

Accepted Answer

This response gives the control to the client and explains what has just occurred.

Question 9

The nurse is assessing a client who is 36 weeks pregnant. Her current pulse is 101 bpm, which represents an increase of 10 bpm since her first assessment at 9 weeks of gestation. Which is the nurse's best action related to this assessment finding?
A)Document the finding, because it is considered within normal limits.
B)Retake the pulse in 15 minutes and ask the client to lie quietly during this time.
C)Teach the client to take her pulse and to record it twice a day.
D)Report the assessment finding to the healthcare provider (HCP)immediately.

Accepted Answer

An increase in the pulse rate of approximately 10 bpm during pregnancy is considered normal and should be documented.

Question 10

The nurse is admitting a client to the labor and delivery unit who states she is at 39 weeks and began having steady contractions approximately 6 hours ago. Which assessment findings discovered during the nurse's vaginal examination would indicate that this client will deliver within the next few hours? Select all that apply.
A)The client's cervix is dilated 7 centimeters.
B)The client's cervix is effaced 20%.
C)The presenting part of the fetus is at -4 station.
D)The client's membranes appear to have ruptured.
E)There is the presence of a bloody show on the nurse's gloved hand.

Accepted Answer

Cervical dilation of 7 cm indicates that labor is progressing and birth can be expected within the next few hours.
Ruptured membranes indicate that birth will occur soon.
Bloody show on the nurse's glove indicates that the client's mucous plug has been lost and is indicative that the client is in the active stage of labor.

Question 11

The nurse is admitting a client to the labor and delivery unit and is preparing to apply the tocodynamometer (toco). Which must the nurse do first to properly apply this equipment?
A)Apply ultrasound gel to the client's abdomen before applying the toco.
B)Determine the fetal position.
C)Locate the uterine fundus.
D)Ensure that the client's membranes have ruptured.

Accepted Answer

The toco should be placed over the uterine fundus because this area is the firmest during a contraction.

Question 12

The certified nurse-midwife (CNM)is doing the first prenatal assessment on a client who states she believes she is 6 weeks pregnant. Which assessment finding by the CNM would indicate that this is the correct gestational age?
A)The fundus is palpable just above the symphysis.
B)Chadwick's sign is noted.
C)The fetal heart rate is obtained with a fetoscope.
D)Colostrum is able to be expressed from the nipple.

Accepted Answer

Chadwick's sign (bluish color of the cervix)may be seen at 4 to 6 weeks.

Question 13

The nurse is caring for a client who is 6 cm dilated with a fetus who has been diagnosed with a serious congenital heart defect. The client has rejected the use of continuous fetal monitoring so the nurse will use the Doppler and monitor the fetal heart rate (FHR)at what frequency?
A)Every 45 minutes
B)Every 30 minutes
C)Every 15 minutes
D)Every 5 minutes

Accepted Answer

The high-risk client in the first stage of labor should have the FHR monitored every 15 minutes.

Question 14

The nurse is admitting a client at full term to the labor and delivery unit. Using Leopold's maneuvers, the nurse determines that the fetus is in the left sacroanterior position (LSA)position and will obtain the fetal heart rate (FHR)at which site on the client's abdomen?
A)Midline, directly above the symphysis pubis
B)To the right of the client's umbilicus
C)To the left of the client's umbilicus
D)To the left, below the umbilicus

Accepted Answer

The fetus is in the LSA, which means it is in the breech position and the back of the fetus is to the right so the FHR will best be heard on the client's right side around the level of the umbilicus.

Question 15

The nurse is assessing a pregnant client who is at 29 weeks gestation. The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex. Which assessment findings led the nurse to document this finding?
A)There was no response when the area directly above the knee was struck with the percussion hammer.
B)The nurse noted an extension of the leg when the percussion hammer touched the area above the knee.
C)The client complained of pain when the foot was dorsiflexed.
D)The client's foot tapped against the nurse's hand when it was dorsiflexed.

Accepted Answer

When the foot taps or jerks against the hand of the nurse who dorsiflexes the client's foot, it indicates clonus and may indicate severe hyperreflexia.

Question 16

The nurse is using a Doppler for obtaining the fetal heart tone of a client who is at 28 weeks gestation and obtains a rate of 98 bpm. Which is the nurse's next action for this client?
A)Take the client's pulse while monitoring the fetal heart rate.
B)Massage the client's abdomen and retake the fetal heart tone.
C)Distract the client and retake the fetal heart tone.
D)Request the healthcare provider (HCP)assess the client for possible fetal compromise.

Accepted Answer

When obtaining the fetal heart rate, the nurse should be prepared to compare the client's heart rate with the fetal heart rate obtained. If they are the same, the Doppler is actually hearing the client's heart rate.

Question 17

A 16-year-old client comes to the prenatal clinic and is very concerned about a black line that has appeared on her abdomen. Which statement by the nurse will be most helpful to this client concerning this issue?
A)"This line occurs depending upon the sex of your baby. I don't want to tell you which one in case you don't know the gender of your baby yet."
B)"This line indicates that you are getting too much iron in your diet. You need to reduce the amount of red meat you are eating."
C)"This line is called the linea nigra and is related to the increase in your hormones during pregnancy."
D)"Please don't be worried about this. It is normal and it will go away after you have your baby."

Accepted Answer

The linea nigra is related to increased hormone levels and should fade considerably after the birth of the baby.

Question 18

The nurse is caring for a client receiving oxytocin for induction of labor and notes that the client's contraction pattern shows a duration of 100 seconds and a frequency of 90 seconds. Which is the nurse's next action at this time?
A)Document the contraction pattern.
B)Inform the healthcare provider that a birth is imminent.
C)Stop the oxytocin.
D)Increase the oxytocin because the contractions are not adequate.

Accepted Answer

The oxytocin must be stopped immediately because the uterus is hyperstimulated, which is preventing adequate oxygen from getting to the fetus.

Question 19

The nurse is caring for a client at 33 weeks gestation who is being monitored for possible preeclampsia. The nurse prepares to check the client's patellar deep tendon reflex and places the client in which position?
A)Ask the client to lay on her left side with the right leg slightly bent and the nurse supporting the client's knee.
B)Request the client lie on her back with the knees bent and the nurse supports on the legs.
C)Sit the client up in bed with the knees bent and the feet resting on the bed.
D)Assist the client to a chair next to the bed and ask the client to cross her legs.

Accepted Answer

To elicit a patellar deep tendon reflex on an inpatient, the client is asked to lie supine with the knees flexed with the nurse supporting the client's leg.

Question 20

The nurse assesses the fundus of a client who delivered 6 hours ago and notes that it is 2 centimeters above the umbilicus and is displaced to the right. Which is the nurse's best action at this time?
A)Begin to massage the fundus.
B)Attempt to move the fundus back to midline.
C)Request the client go to the bathroom and void.
D)Determine if this client has had more than one child in the last 3 years.

Accepted Answer

A fundus that is elevated and displaced to the right indicates that the client's bladder may be full. The nurse should ask the client to void and then check again.

Quiz 65: Reproduction

The nurse is assisting the health care provider with the first prenatal exam of a client. Prior to the vaginal speculum examination, which information should the nurse give the client to improve the client's comfort during the examination?

The nurse is caring for a client who is prescribed to have labor induced with oxytocin. Which assessments must be completed by the nurse before initiating the oxytocin infusion? Select all that apply.

The nurse has completed applying the ultrasound transducer to the client's abdomen and has confirmed that the rate is not the same as the client's. Which other assessment will assist the nurse in confirming that the sound that is heard is the true fetal heart rate (FHR) ?

The nurse is discussing anticipated weight gain with a client who has a BMI of 32. Which statement by the client indicates understanding of the topic?

The nurse is caring for a woman who has been diagnosed with preeclampsia and has been placed on intravenous magnesium sulfate to prevent seizures. After checking the patellar deep tendon reflex, the nurse documents the response as 2+. Which is the nurse's next action after this assessment?

The nurse is performing the first Leopold maneuver on a client of 34 weeks gestation and notes the presence of fetal bottom and legs. The nurse knows that this maneuver would indicate which for this client?

The nurse is assessing a client who is 36 weeks pregnant. Her current pulse is 101 bpm, which represents an increase of 10 bpm since her first assessment at 9 weeks of gestation. Which is the nurse's best action related to this assessment finding?

The nurse is admitting a client to the labor and delivery unit and is preparing to apply the tocodynamometer (toco) . Which must the nurse do first to properly apply this equipment?

The certified nurse-midwife (CNM) is doing the first prenatal assessment on a client who states she believes she is 6 weeks pregnant. Which assessment finding by the CNM would indicate that this is the correct gestational age?

The nurse is caring for a client who is 6 cm dilated with a fetus who has been diagnosed with a serious congenital heart defect. The client has rejected the use of continuous fetal monitoring so the nurse will use the Doppler and monitor the fetal heart rate (FHR) at what frequency?

The nurse is admitting a client at full term to the labor and delivery unit. Using Leopold's maneuvers, the nurse determines that the fetus is in the left sacroanterior position (LSA) position and will obtain the fetal heart rate (FHR) at which site on the client's abdomen?

The nurse is assessing a pregnant client who is at 29 weeks gestation. The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex. Which assessment findings led the nurse to document this finding?

The nurse is using a Doppler for obtaining the fetal heart tone of a client who is at 28 weeks gestation and obtains a rate of 98 bpm. Which is the nurse's next action for this client?

A 16-year-old client comes to the prenatal clinic and is very concerned about a black line that has appeared on her abdomen. Which statement by the nurse will be most helpful to this client concerning this issue?

The nurse is caring for a client receiving oxytocin for induction of labor and notes that the client's contraction pattern shows a duration of 100 seconds and a frequency of 90 seconds. Which is the nurse's next action at this time?

The nurse is caring for a client at 33 weeks gestation who is being monitored for possible preeclampsia. The nurse prepares to check the client's patellar deep tendon reflex and places the client in which position?

The nurse assesses the fundus of a client who delivered 6 hours ago and notes that it is 2 centimeters above the umbilicus and is displaced to the right. Which is the nurse's best action at this time?